Maxillary Osteotomies and Bone Grafts for

Correction of Contoural and Occlusal

Deformities*®

M. L. LEWIN, M.D.

RAVELO V. ARGAMASO, M.D.

ABRAHAM I. FINGEROTH, D.D.S.Bronx, New York

One of the major aims of modern management of the cleft palate

patient is the prevention of skeletal deformity. With present day surgical

management and orthodontic treatment, pronounced maxillary hypoplasia

is rarely encountered. Severe hypoplasia of the entire maxillary compound

is seen in other congenital malformations, as in Crouzon's disease.

For some patients who have a striking disproportion between the max-

illa and the mandible with pseudo prognathism, mandibular osteotomy

with recession of the mandible will restore the occlusal relationship and

correct the contoural deformity (Figure 1).

Skeletal deformities in cleft palate patients are usually limited to the

alveolar portion of the maxilla. The recession of the maxilla in such

patients may often be improved by prosthetic restoration. When the upper

jaw is edentulous or nearly so, a denture will establish satisfactory contour

and occlusion. Occasionally, the upper suleus is deepened to accom-

modate a larger labial component. A denture will not correct the deform-

ity when there is hypoplasia of the entire maxillary compound. If maxil-

lary hypoplasia exists without concomitant malocclusion, onlay bone

grafts to the anterior facial wall will improve the facial contour (7, 8)

(Figure 2). However, maxillary hypoplasia is generally associated with

severe malocclusion and can only be corrected by midface osteotomy.

Facial osteotomies are based on the work of LeFort who studied the

mechanism of fractures of the facial skeleton. Because of the variations in

the strength and fragility of various parts of the facial skeleton, fractures

of the face usually follow a typical pattern.

The most severe fracture leads to separation of the facial skeleton from

the cranial base and is known as LeFort III' (6). The more common is the

LeFort I fracture in which the alveolar process is severed horizontally

from the maxillary wall and from the pterygoid buttresses (Figure 3a).

An elective osteotomy of the entire maxilla was first reported about

* From the Plastic Surgery Division. Department of Surgery, and Cleft Palate Cen-ter, Montefiore Hospital and Medical Center.

' LeFort II is similar to LeFort III, except that the fracture line runs across thepyriform aperture instead of through the naso-frontal junction.

18

MAXILLARY O§STEOTOMIES AND BONE GRAFTS 10

FIGURE la & b. Mild maxillary hypoplasia and mandibular prognathism cor-

rected by ositcotomy of the mandible {and rhinoplasty).

FIGURE 2a & b. Crouzon syndrome of moderate severity without malocclusion,corrected by bone grafts of the infraorbital area (b. ten years after operation}.

twonty years ago by Gillies and Harrison. (3). The main difficulty they

cneountored was in maintaining the maxilla in its advanced position. In

spite of intra and estraoral traction and fixation, the maxilla recessed

during the postoperative period. Although Gillies case was considered a

20 Lewin, Argamaso, Fingeroth

FIGURE 3 a. Lincs of osteotomy according to LeFort: TII (solid black linc), Le-Fort 1 interrupted line. b. Site of osteotomies at the pterygopalatal junction. c. Facialskeleton detached from the base of the skull. d. Locations of bone grafts.

success, his experionce discouraged many surgeons from following this

approach.

A major contribution to this work was made by Paul Tessier, who

combined the osteotomy with bone grafts (18, 14). These bone grafts were

intended to prevent the advanced maxilla from receding and to assure

firm and rapid union. Murray and Swanson, (10) Jabaley and Edgerton,

(4) Obwegeser (11) published case reports of LeFort III osteotomies and

described details of the surgical procedure.

Obwegeser (12) recommended a variety of major and mimor maxillary

osteotomies for the correction of facial deformities, secondary to cleft

palate, or of other etiology.

The operation for midface advancement consists of seven incisions and

seven ostcotomics, the latter being joined together to encircle the maxilla.

Five incisions are made on the face and two intraorally in the upper

buccal suleus in the retromolar area, to gain access to the pterygopalatal

junction.

An incision across the glabella, from one eanthus to the other, exposes

the fronto-nasal junction and the medial orbital wall. The lateral orbital

MAXILLARY OSTEOTOMIES AND BONE GRAFTS 21

wall, the zygoma, the postero-lateral surface of the maxilla, are reached

through incisions, continuous with the eyebrow on both sides. These three

incisions can be avoided by turning down a frontal skin flap by means of

a coronal incision, extending from one ear to the other.

The floor of the orbit is exposed subperiostally through an incision in

the lower lid.

The lines of the periorbital osteotomies are presented (Figures 3a &

3b). The procedure is done under direct vision, which later permits the

accurate placement of bone grafts (Figure 83d). The intraoral osteotomy

and the one on the postero-lateral wall of the maxilla, is done blindly in a

tunnel which joins the lateral periorbital incision with the intraoral. The

correct placement of a bone block in the pterygoid area is technically diffi-

cult.

The last step of the osteotomy consists of cutting through the nasal

septum from the fronto-nasal junction to the palate. The mobilization of

the maxilla is accomplished by forceful traction, or rocking with a disim-

paction forceps, to loosen the firm, soft tissue attachments. The tearing of

the nasal and maxillary sinus mucosa at this stage does not seem to

interfere with the smooth take of the bone grafts.

The operation spares the lacrimal apparatus (the osteotomy on the

medial wall of the orbit is performed posterior to the lacrimal fossa so

that the lacrimal sac and the duct are included in the advanced frag-

ment), and the infraorbital nerve, which is freed in its bony canal. Sub-

periosteal exposure of the orbital skeleton preserves the periosteal mantle

and does not interfere with the orbital content.

The objective of the operation is to mobilize a monoblock, encompass-

ing the midfacial skeleton, which can be advanced and maintained in the

new position. Splintering of the maxilla would make both the advance-

ment and the immobilization difficult.

When one visualizes the facial skeleton with maxilla advanced, it be-

comes apparent that bone grafts are essential for the success of the opera-

tion (Figures 3¢ & 3d). Without them, it is inconceivable that the advanced

position could be maintained and still have bony union and stability. The

gap at the various osteotomy sites ranges from 1-24 ems or more, depend-

ing on the case. This calls for large blocks of cancelous bone which must be

held in place by wiring.

The operation is time consuming and associated with substantial blood

loss which must be replaced.

Post-operative immobilization is important and consists primarily of

intermaxillary fixation (Figure 4d). In our cases, extraoral traction was

maintained on the orbital rim for four-six weeks. We found the Mills

diadem an effective, simple and inexpensive apparatus (9) (Figure 5a).

The intermaxillary fixation, accomplished with wires, and later with elas-

tics, was maintained constantly or intermittently for more than three

months. Firm consolidation was established.

FIGURE 4. Sevore facial deformity in Grouzon discase in a 20 year old girl. a, b.

Preoperative and postoperative profile. e, d. Preoperative and postoperative occlusion.

c, {. Preoperative and postoperative radiographs. Note degree of raidface advancement

and postoperative occlusion.

MAXILLARY OSTEOTOMIES AND BONE GRAFTS 23

FIGURE 5. a. Postoperative extraoral tractions using Mills diadem, (same patientas in Fig. 4). b. Preoperative and postoperative dental molds.

In our limited experience, some recession of the advanced maxilla did

occur, but there was no tendency for the deformity to reeur. The new

occlusal relation was maintained (Figures 4 & 5).

LeFort I osteotomy is occasionally indicated in cleft palate rehabilita-

tion. However, much more often there are indications for segmental osteot-

omy of the maxilla (1, 2). The place of this procedure in rehabilitation of

the older cleft palate patient has not been fully appreciated. When there

are teeth in the upper jaw and the occlusal relationship is grossly dis-

turbed, beyond the seope of orthodontic improvement, surgical reposition-

ing should be considered. The lingual displacement of the anterior frag-

ment causes recession of the upper lip and unattractive flatness of the

facial contour. This is an additional indication for osteotomy.

Patient shown Figure 6 had a segmental osteotomy of the maxilla as a

stage in the rehabilitation of his cleft lip and palate. The exact size of the

osteotomized segment is determined by a study of the occlusal models

(Figure 6f). The alveolar fragment is mobilized by osteotomies on its

buccal and palatal surfaces. The soft tissue attachment on the palatal

surface must be freed to expose the predetermined osteotomy site and to

allow for the advancement of the fragment. The osteotomy on the buccal

surface is performed through short vertical incisions and tunnelling, leav-

ing sufficient mucosal attachment to assure the viability of the osteoto-

mized segment. Intermaxillary fixation is an important step in the proce-

dure. Cancelous bone grafts are usually essential to assure firm and rapid

union.

Summary

Maxillary osteotomies of LeFort I or III types and segmental ostcoto-

mies of the maxilla and palate bring us a step forward in the surgical

rehabilitation of patients with severe facial deformities. Partial (cortical)

24 Lewin, Argamaso, Fingeroth

FIGURE 6. 32 year old male with contoural and malocclusal deformity, secondaryto cleft lip and palate. a, b. Preoperative appearance. c. Augmentation of upper lipwith small Abbe flap, corresponding to site of philtrum. d, e. Postoperative appear-ance. f. Preoperative and postoperative dental models and the site of palatal oste-otomy.

or complete osteotomies with bone grafts have an important role, though

not yet fully exploited, in the orthodontic treatment of severe occlusal

deformities.

References

1. J. M., Horowitz, S. L., Guy, C. L., and D., Surgical-ortho-dontic corrections in the bilateral cleft lip. Cleft Palate J., 1, 153-163, 1964.

2. J. M., and Horowitz, S. L., The surgical-orthodontic approach to thetreatment of dentofacial deformities. Amer. J. of Orthodontics, 55, 217-243, 1969.

3. H. and Harrison, S. H., Operative correction by osteotomy of recessedmalar maxillary compound in a case of oxycephaly. Brit. J. Plast. Surg., 8, 123-127, 1951.

4. JaBsueEy, M. E. and Enoerrton, M. T., Surgical correction of congenital midfaceretrusion in the presence of mandibular prognathism. Plast. & Rec. Surg., 44, 1-8,1969.

. Kxowrrs, C. C., The place of mandibular osteotomy in the treaiment plan forcleft lip and palate conditions. Brit. J. Plast. Surg., 23, 365-369, 1969.

6. LeFort, R., Etude experimentale sur les fractures de le machoire superieure. Rev.Chir. Paris, 28, 208, 360, 479, 1901.

Ot

12.

18.

14.

MAXILLARY OSTEOTOMIES AND BONE GRAFTS 25

. Lewin, M. L., Facial and hand deformities in acrocephalosyndactyly. Plastic andReconstructive Surgery, 12, 188-147, 1953.

. Lewin, M. L., Facial deformity in acrocephaly and its surgical co'rection. Arch. ofOphthalmology, 47, 321-327, 1952.

. MILs, R., Personal Communications.

. Murray, J. E. and Swanson, L. T., Mid-face osteotomy and advancement forcraniosynostosis. Plast. & Reconst. Surg., 41, 299-306, 1968.

. OsBwrarsEr, H. L., Surgical correction of small or retrodisplaced maxilla. The"dish face" deformity. Plast. & Reconst. Surg., 48, 351-865, 1969.

H. L., Surgery as an adjunct to orthodontics in normal and cleftpalate patients. Trans. of European Orthodontic Soc., 42, 343-3583, 1966.T'rssier, P., Osteotomies totales de la face syndrome de Crouzon syndrome d'apert,oxycephalies, scaphocephalies, turricephalies. Ann. Chir. Plast. XII, CP 273-286, 1967.T'rssiIERr, P., Private Communications, Seminar, Centre Medico-Chirugical FOCH,Suresnes, France.